Making Pregnancy Safer for Women of Color

Second, she sees her ancillary staff — receptionists, medical assistants and educators — not as her assistants or the people who get the patient ready to see the provider, but as critical parts of the team that help mothers get to term safely. She will often emphasize that the time her clients spend with her staff is more important than the time spent with her or another provider in her practice.

Third, she goes to great lengths to insure that she and her staff treat patients with respect and consideration. The women come in looking like “deer in headlights,” said Gloribel Parra, a Latina doula volunteering at Joseph’s clinic. “Once they leave they are breathing easier and have someone they can go to if they have questions,” she said.

It’s hard to overstate how important the accessibility of Joseph’s model is for the women seeking her care. “Most of the people who are truly disenfranchised and at risk can’t get past the front desk anymore,” Joseph said, describing the situation at many other prenatal care settings. “They may bounce up to your clinic: ‘Hey, I need prenatal care.’ ‘Well, have you got money? Have you got Medicaid?’ ” And if the answer is no, she recounts, the bottom line is “ ‘Then go away.’ ” Joseph says that clinics that used to bill patients after visits are now requiring cash payment up front.

The local health department, she said, “has become so short of cash they have to charge you as well. If you can’t pay, you can’t get started.”

The first tenet of Joseph’s model is offering access. She isn’t helping only women who can’t afford to pay. She also helps women with pregnancies that other clinics deem too high risk to handles. And she won’t turn away anyone on the basis of how far along her pregnancy is. “We regularly deal with tears at the front door,” she said. Patients tell her, “I can’t believe you’re actually going to help me.”

The other three tenets are connection, education and empowerment. Her staff members are the main drivers of this, a group carefully chosen for their empathetic approach. “I was 19 when I had my son — a single black mom with no family support because my parents were mad,” said Trina Nelson, who has been working with Joseph for 12 years. “I’m 35, so now I’m, like, ‘Let me help these women because I was there before, I know.’”

Nelson spends much of her time texting and calling clients who can reach her 24/7. “When a patient of ours says, ‘I’ve got a question,’ I want it answered,” Joseph said. This level of accessibility is extremely unusual; at many other clinics, you have only a few minutes with your provider to raise questions and have them answered.

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Another element that contributes to Joseph’s effectiveness can be found in a growing body of research into links between stress, discrimination and maternal health.

Joseph and others believe those factors contribute to the high rates of maternal illness among African-American women. “The daily assault that you deal with, just being of color, it’s so lethal,” she said. “The stress, the judgment, it’s killing our babies.”

David Williams, a Harvard sociologist who pioneered the survey instruments that document the connection between discrimination and disease, explained that discrimination “leads to a number of preclinical indicators of health problems,” including high blood pressure and inflammation. “We have a number of studies that indicate that discrimination is also directly linked to poor health outcomes,” he said. “The evidence is quite striking.”

By providing easy access to prenatal care, and an environment that insures that women feel respected, cared for and fully supported, Joseph believes she is creating a buffer against the daily stress facing her clients. Clinics that make getting care stressful by treating clients with disrespect or operating on race and gender stereotypes can add a new source of trauma, further endangering women during the vulnerable time that is pregnancy.

So far, Joseph’s outcomes for the 600 or so women she sees annually have been impressive. A recent outside evaluation of her work funded by the West Orange Health Care District found preterm birth and low-infant birth weight rates among her patients significantly lower than rates in other settings. Joseph’s clients of African descent were almost 40 percent less likely than women of a similar race throughout the nation to have a preterm labor or a child with a low birth weight.

These findings are consistent with two earlier outside evaluations of Joseph’s work, and further illustrate that her model is an unusual bright spot for a problem that is worsening in most areas, not improving.

But while Joseph’s model is low-cost and accessible, there are certainly hurdles to replicating it. Joseph spends countless hours trying to get Florida Medicaid to enroll her pregnant clients, and then many more hours chasing down the $50 per appointment fee that Medicaid will pay. Her financial model is lean — a staff made up of midwives and medical assistants means the salaries are more manageable.

Joseph would love to hire a full-time nurse practitioner, but doesn’t have the money. She’s had some success raising funds through her associated nonprofit, but those are generally restricted to programs, not salaries. She often deals with a lack of cash and burnout.

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Her approach is also not a magic bullet for larger systemic issues facing poor women and women of color. While Joseph has made major strides, her clients’ difficulties don’t begin with illness and disease during pregnancy, and they certainly don’t stop there.

A 27-year-old African-American client whose child had come through pregnancy and birth healthy told me that she was now struggling financially. A medical complication after birth had caused a longer than expected time away from her job, and now she wasn’t sure if she could cover her rent and food bills. A clinic employee sent her off with diapers, formula and phone numbers for food banks, but none of the mother’s larger problems would be solved by these stopgap measures.

Other providers have tried to use Joseph’s model, but she isn’t sure if they are applying it faithfully enough to produce the same results. While her method doesn’t depend on expensive medicine or technology, it does require fundamental shifts in the approach to health care. They include valuing the role of the staff from the front desk to the head practitioner, and approaching women who often suffer implicit bias with respect and a belief that they can achieve a healthy pregnancy despite the odds against them.

But of course, the potential payoffs of Joseph’s model — the provision not only of respectful care to marginalized women but also a path to ameliorating a longstanding and difficult-to-address public health problem across the nation — are worth striving for.